Injuries of the clavicle acromioclavicular joint and sternoclavicular joint
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Injuries of the Clavicle, Acromioclavicular Joint and Sternoclavicular Joint. Andrew H. Schmidt, M.D. T.J. McElroy Created March 2004; Revised January 2007. Clavicle. “S”-shaped bone Medial - sternoclavicular joint Lateral - acromioclavicular joint and coracoclavicular ligaments

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Injuries of the clavicle acromioclavicular joint and sternoclavicular joint

Injuries of the Clavicle, Acromioclavicular Joint and Sternoclavicular Joint

Andrew H. Schmidt, M.D.

T.J. McElroy

Created March 2004; Revised January 2007


Clavicle
Clavicle Sternoclavicular Joint

  • “S”-shaped bone

  • Medial - sternoclavicular joint

  • Lateral - acromioclavicular joint and coracoclavicular ligaments

  • Muscle attachments:

    • Medial: sternocleidomastoid

    • Lateral: Trapezius, pectoralis major


Ac joint
AC Joint Sternoclavicular Joint

  • Diarthrodial joint between medial facet of acromion and the lateral (distal) clavicle.

  • Contains intra-articular disk of variable size.

  • Thin capsule stabilized by ligaments on all sides:

    • AC ligaments control horizontal (anteroposterior ) displacement

    • Superior AC ligament most important


Distal clavicle
Distal Clavicle Sternoclavicular Joint

  • Coracoclavicular ligaments

    • “Suspensory ligaments of the upper extremity”

    • Two components:

      • Trapezoid

      • Conoid

    • Stronger than AC ligaments

    • Provide vertical stability to AC joint


Mechanism of injury
Mechanism of Injury Sternoclavicular Joint

Moderate or high-energy traumatic impacts to the shoulder

  • Fall from height

  • Motor vehicle accident

  • Sports injury

  • Blow to the point of the shoulder

  • Rarely a direct injury to the clavicle


Physical examination
Physical Examination Sternoclavicular Joint

  • Inspection

    • Evaluate deformity and/or displacement

    • Beware of rare inferior or posterior displacement of distal or medial ends of clavicle

    • Compare to opposite side.


Physical examination1
Physical Examination Sternoclavicular Joint

  • Palpation

    • Evaluate pain

    • Look for instability with stress


Physical examination2
Physical Examination Sternoclavicular Joint

  • Neurovascular examination

  • Evaluate upper extremity motor and sensation

  • Measure shoulder range-of-motion


Radiographic evaluation of the clavicle
Radiographic Evaluation Sternoclavicular Jointof the Clavicle

  • Anteroposterior View

  • 30-degree Cephalic Tilt View


Radiographic evaluation of the clavicle1
Radiographic Evaluation of the Clavicle Sternoclavicular Joint

  • Quesana View

    • 45-degree angle superiorly and a 45-degree angle inferiorly

    • Provide better assessment of the extent of displacement


Radiographic evaluation of the ac joint
Radiographic Evaluation Sternoclavicular Jointof the AC Joint

  • Zanca View

    • AP view centered at AC joint with 10 degree cephalic tilt

    • Less voltage than used for AP shoulder


Stress views of the distal clavicle ac joint
Stress Views of the Distal Clavicle & AC Joint Sternoclavicular Joint

  • Rationale: will demonstrate instability and differentiate grade III AC separations from partial Grade I-II injuries

  • Performed by having patient hold 10# weight with injured arm

  • Rarely used today, since most AC joint injuries treated the same, and management of distal clavicle fractures depends on initial displacement and location of fracture.


Radiographic evaluation of the medial one third
Radiographic Evaluation of the Medial One Third Sternoclavicular Joint

  • X-ray: Cephalic tilt view of 40 to 45 degrees

  • CT scan usually indicated to best assess degree and direction of displacement


Clavicle fractures
Clavicle Fractures Sternoclavicular Joint


Classification of clavicle fractures
Classification of Sternoclavicular JointClavicle Fractures

  • Group I : Middle third

    • Most common (80% of clavicle fractures)

  • Group II: Distal third

    • 10-15% of clavicle injuries

  • Group III: Medial third

    • Least common (approx. 5%)


Treatment options
Treatment Options Sternoclavicular Joint

  • Nonoperative

    • Sling

    • Brace

  • Surgical

    • Plate Fixation

    • Screw or Pin Fixation


Nonoperative treatment
Nonoperative Treatment Sternoclavicular Joint

  • “Standard of Care” for most clavicle fractures.

  • Continued questions about the need to wear a specialized brace.


Simple sling vs figure of 8 bandage
Simple Sling vs. Sternoclavicular JointFigure-of-8 Bandage

  • Prospective randomized trial of 61 patients

  • Simple sling

    • Less discomfort

  • Functional and cosmetic results identical

  • Alignment of healed fractures unchanged from the initial displacement in both groups

Andersen et al., Acta Orthop Scand 58: 71-4, 1987.


Nonoperative treatment1
Nonoperative Treatment Sternoclavicular Joint

  • It is difficult to reduce clavicle fractures by closed means.

  • Most clavicle fractures unite rapidly despite displacement

  • Significantly displaced mid-shaft and distal-third injuries have a higher incidence of nonunion.


Nonoperative treatment2
Nonoperative Treatment Sternoclavicular Joint

  • There is new evidence that the outcome of nonoperative management of displaced middle-third clavicle fractures is not as good as traditionally thought, with many patients having significant functional problems.


Deficits following nonoperative treatment of displaced midshaft clavicular fractures
Deficits following nonoperative treatment of displaced midshaft clavicular fractures

  • A patient-based outcome questionnaire and muscle-strength testing were used to evaluate 30 patients after nonoperative care of a displaced midshaft fracture of the clavicle.

  • At a minimum of twelve months (mean 55 mos), outcomes were measured with the Constant shoulder score and the DASH patient questionnaire. In addition, shoulder muscle-strength testing was performed with the Baltimore Therapeutic Equipment Work Simulator, with the uninjured arm serving as a control.

McKee et al. J Bone Joint Surg Am 2006;88-A:35-40.


Deficits following nonoperative treatment of displaced midshaft clavicular fractures1
Deficits following nonoperative treatment of displaced midshaft clavicular fractures

  • The strength of the injured shoulder was 81% for maximum flexion, 75% for endurance of flexion, 82% for maximum abduction, 67% for endurance of abduction, 81% for maximum external rotation, 82% for endurance of external rotation, 85% for maximum internal rotation, and 78% for endurance of internal rotation (p < 0.05 for all).

  • The mean Constant score was 71 points, and the mean DASH score was 24.6 points, indicating substantial residual disability.

McKee et al. J Bone Joint Surg Am 2006;88-A:35-40.



Definite indications for surgical treatment of clavicle fractures
Definite Indications for Surgical Treatment of Clavicle Fractures

  • 1) Open fractures

  • 2) Associated neurovascular injury


Relative indications for acute treatment of clavicle fractures
Relative Indications for Acute Treatment of Clavicle Fractures

  • 1) Widely displaced fractures

  • 2) Multiple trauma

  • 3) Displaced distal-third fractures


Relative indications for acute treatment of clavicle fractures1
Relative Indications for Acute Treatment of Clavicle Fractures

  • 4) Floating shoulder

  • 5) Seizure disorder

  • 6) Cosmetic deformity

  • 7) Earlier return to work.


Clavicular displacement
Clavicular Displacement Fractures

  • < 5 mm shortening: acceptable results at 5 years (Nordqvist et al, Acta Orthop Scand 1997;68:349-51.

  • > 20 mm shortening associated with increased risk of nonunion and poor functional outcome at 3 years (Hill et al, JBJS 1997;79B: 537-9)


Plate fixation
Plate Fixation Fractures

  • Traditional means of ORIF

  • Plate applied superiorly or inferiorly

    • Inferior plating associated with lower risk of hardware prominence

  • Used for acute displaced fractures and nonunions.


Intramedullary fixation
Intramedullary Fixation Fractures

  • Large threaded cannulated screws

  • Flexible elastic nails

  • K-wires

    • Associated with risk of migration

  • Useful when plate fixation contra-indicated

    • Bad skin

    • Severe osteopenia

  • Fixation less secure


Complications of clavicular fractures and its treatment
Complications of Clavicular Fractures and its Treatment Fractures

  • Nonunion

  • Malunion

  • Neurovascular Sequelae

  • Post-Traumatic Arthritis


Risk factors for the development of clavicular nonunions
Risk Factors for the Development of Clavicular Nonunions Fractures

  • Location of Fracture

    • (outer third)

  • Degree of Displacement

    • (marked displacement)

  • Primary Open Reduction


Principles for the treatment of clavicular nonunions
Principles for the Treatment of Clavicular Nonunions Fractures

  • Restore length of clavicle

    • May need intercalary bone graft

  • Rigid internal fixation, usually with a plate

  • Iliac crest bone graft

    • Role of bone-graft substitutes not yet defined.



Clavicular malunion
Clavicular Malunion Fractures

  • Symptoms of pain, fatigue, cosmetic deformity.

  • Initially treat with strengthening, especially of scapulothoracic stabilizers.

  • Consider osteotomy, internal fixation in rare cases in which nonoperative treatment fails.

Correction of malunion with thoracic outlet sx


Neurologic sequelae
Neurologic Sequelae Fractures

  • Occasionally, fracture fragments or abundant callus can cause brachial plexus symptoms.

  • Treatment is reduction and fixation of the fracture, or resection of callus with or without osteotomy and fixation for malunions.


Osteotomy for clavicular malunion
Osteotomy for Clavicular Malunion Fractures

  • 15 patients with malunion after nonoperative treatment of a displaced midshaft clavicle fracture of the clavicle. Average clavicular shortening was 2.9 cm (range, 1.6 to 4.0 cm).

  • Mean time from the injury to presentation was three years (range, 1 to 15 years).

  • Outcome scores revealed major functional deficits.

  • All patients underwent corrective osteotomy of the malunion through the original fracture line and internal fixation.

McKee MD, et al. J Bone Joint Surg Am 2003;85-A(5):790-7


Osteotomy for clavicular malunion1
Osteotomy for FracturesClavicular Malunion

  • At follow-up (mean 20 months postoperatively) the osteotomy site had united in 14 of 15 patients.

  • All 14 patients satisfied with the result.

  • Mean DASH score for all 15 patients improved from 32 points preoperatively to 12 points at the time of follow-up (p = 0.001).

  • Mean shortening of the clavicle improved from 2.9 to 0.4 cm (p = 0.01).

  • There was 1 nonunion, and 2 patients had elective removal of the plate.

McKee MD, et al. J Bone Joint Surg Am 2003;85-A(5):790-7



Classification of distal clavicular fractures group ii clavicle fractures
Classification of Distal Clavicular Fractures Fractures(Group II Clavicle Fractures)

  • Type I-nondisplaced

    • Between the CC and AC ligaments with ligament still intact

From Nuber GW and Bowen MK, JAAOS, 5:11, 1997


Classification of distal clavicular fractures
Classification of Distal Clavicular Fractures Fractures

  • Type II

    • Typically displaced secondary to a fracture medial to the coracoclavicular ligaments, keeping the distal fragment reduced while allowing the medial fragmetn to displace superiorly

    • Highest rate of nonunion (up to 30%)

    • Two Types


Type iia
Type IIA Fractures

  • A. Conoid and trapezoid attached to distal fragment

From Nuber GW and Bowen MK, JAAOS, 5:11, 1997


Type iib
Type IIB Fractures

  • Type IIB: Conoid torn, trapezoid attached

From Nuber GW and Bowen MK, JAAOS, 5:11, 1997


Classification of distal clavicular fractures1
Classification of Distal Clavicular Fractures Fractures

  • Type III:articular fractures

From Nuber GW and Bowen MK, JAAOS, 5:11, 1997


Treatment of distal third type ii clavicle fractures
Treatment of Distal-Third (Type II) Clavicle Fractures Fractures

  • Nonoperative treatment

    • 22 to 33% failed to unite

    • 45 to 67% took more than three months to heal

  • Operative treatment

    • 100% of fractures healed within 6 to 10 weeks after surgery



Techniques for acute operative treatment of distal clavicle fractures
Techniques for Acute Operative Treatment of Distal Clavicle Fractures

  • Kirschner wires inserted into the distal fragment

  • Dorsal plate fixation

  • CC screw fixation

  • Tension-band wire or suture

  • Transfer of coracoid process to the clavicle

  • Clavicular Hook Plate




Hook plate results
Hook Plate - Results designed to avoid this problem of redisplacement.

  • Recent series of distal clavicle fractuers treated with the Hook Plate document high union rates of 88% - 100%. Complications are rare but potentially significant, including new fracture about the implant, rotator cuff tear, and frequent subacromial impingement.


Preferred technique for fixation of acute distal third clavicle fractures
Preferred Technique for Fixation of Acute Distal Third designed to avoid this problem of redisplacement.Clavicle Fractures

  • Horizontal incision

  • Manual reduction of fracture

  • Dorsal tension band suture and reconstruction/augmentation of coracoclavicular ligaments.


Indications for late surgery for distal clavicle fractures
Indications for Late Surgery for Distal Clavicle Fractures designed to avoid this problem of redisplacement.

  • Pain

  • Weakness

  • Deformity


Techniques for late surgery for distal clavicle fractures
Techniques for Late Surgery for Distal Clavicle Fractures designed to avoid this problem of redisplacement.

  • Excision of distal clavicle

    • With or without reconstruction of coracoclavicular ligaments (Modified Weaver-Dunn procedure)

  • Reduction and fixation of fracture


Case example
Case Example designed to avoid this problem of redisplacement.


Case example1
Case Example designed to avoid this problem of redisplacement.

Medial Clavicle

Distal Clavicle


Case example2

Coracoclavicular fixation not visible designed to avoid this problem of redisplacement.

Case Example

Fixation to Acromion


Acromioclavicular joint
Acromioclavicular Joint designed to avoid this problem of redisplacement.


Radiographic evaluation of the acromioclavicular joint
Radiographic Evaluation of the Acromioclavicular Joint designed to avoid this problem of redisplacement.

  • Proper exposure of the AC joint requires one-third to one-half the x-ray penetration of routine shoulder views

  • Initial Views:

    • Anteroposterior view

    • Zanca view (15 degree cephalic tilt)

  • Other views:

    • Axillary: demonstrates anterior-posterior displacement

    • Stress views: not generally relevant for treatment decisions.


Classification for acromioclavicular joint injuries
Classification for Acromioclavicular Joint Injuries designed to avoid this problem of redisplacement.

  • Initially classified by both Allman and Tossy et al. into three types (I, II, and III).

  • Rockwood later added types IV, V, and VI, so that now six types are recognized.

  • Classified depending on the degree and direction of displacement of the distal clavicle.

Allman FL Jr. Fractures and ligamentous injuries of the clavicle and its articulation. JBJS 49A: 774-784, 1967.

Rockwood CA Jr and Young DC. Disorders of the acromioclavicular joint, In Rockwood CA, Matsen FA III: The Shoulder, Philadelphia, WB Saunders, 1990, pp. 413-476.


Type i
Type I designed to avoid this problem of redisplacement.

  • Sprain of acromioclavicular ligament

  • AC joint intact

  • Coracoclavicular ligaments intact

  • Deltoid and trapezius muscles intact

From Nuber GW and Bowen MK, JAAOS, 5:11, 1997


Type II designed to avoid this problem of redisplacement.

  • AC joint disrupted

  • < 50% Vertical displacement

  • Sprain of the coracoclavicular ligaments

  • CC ligaments intact

  • Deltoid and trapezius muscles intact

From Nuber GW and Bowen MK, JAAOS, 5:11, 1997


Type iii
Type III designed to avoid this problem of redisplacement.

  • AC ligaments and CC ligaments all disrupted

  • AC joint dislocated and the shoulder complex displaced inferiorly

  • CC interspace greater than the normal shoulder(25-100%)

  • Deltoid and trapezius muscles usually detached from the distal clavicle

From Nuber GW and Bowen MK, JAAOS, 5:11, 1997


Type iii variants
Type III Variants designed to avoid this problem of redisplacement.

  • “Pseudodislocation” through an intact periosteal sleeve

  • Physeal injury

  • Coracoid process fracture


Type iv
Type IV designed to avoid this problem of redisplacement.

  • AC and CC ligaments disrupted

  • AC joint dislocated and clavicle displaced posteriorly into or through the trapezius muscle

  • Deltoid and trapezius muscles detached from the distal clavicle

From Nuber GW and Bowen MK, JAAOS, 5:11, 1997


Type v
Type V designed to avoid this problem of redisplacement.

  • AC ligaments disrupted

  • CC ligaments disrupted

  • AC joint dislocated and gross disparity between the clavicle and the scapula (100-300%)

  • Deltoid and trapezius muscles detached from the distal half of clavicle

From Nuber GW and Bowen MK, JAAOS, 5:11, 1997


Type vi
Type VI designed to avoid this problem of redisplacement.

  • AC joint dislocated and clavicle displaced inferior to the acromion or the coracoid process

  • AC and CC ligaments disrupted

  • Deltoid and trapezius muscles detached from the distal clavicle

From Nuber GW and Bowen MK, JAAOS, 5:11, 1997


Treatment options for types i ii acromioclavicular joint injuries
Treatment Options for Types I - II Acromioclavicular Joint Injuries

  • Nonoperative: Ice and protection until pain subsides (7 to 10 days).

  • Return to sports as pain allows (1-2 weeks)

  • No apparent benefit to the use of specialized braces.


  • Type II operative treatment Injuries

    • Generally reserved only for the patient with chronic pain.

    • Treatment is resection of the distal clavicle and reconstruction of the coracoclavicular ligaments.


Treatment options for type iii vi acromioclavicular joint injuries
Treatment Options for Type III-VI Acromioclavicular Joint Injuries

  • Nonoperative treatment

    • Closed reduction and application of a sling and harness to maintain reduction of the clavicle

    • Short-term sling and early range of motion

  • Operative treatment

    • Primary AC joint fixation

    • Primary CC ligament fixation

    • Excision of the distal clavicle

    • Dynamic muscle transfers



Indications for acute surgical treatment of acromioclavicular injuries
Indications for Acute Surgical Treatment of Acromioclavicular Injuries

  • Type III injuries in highly active patients

  • Type IV, V, and VI injuries


Surgical options for ac joint instability
Surgical Options for AC Joint Instability Acromioclavicular Injuries

  • Coracoid process transfer to distal transfer (Dynamic muscle transfer)

  • Primary AC joint fixation

  • Primary Coracoclavicular Fixation

  • Distal Clavicle Excision with CC ligament reconstruction.


Weaver dunn procedure
Weaver-Dunn Procedure Acromioclavicular Injuries

  • The distal clavicle is excised.

  • The CA ligament is transferred to the distal clavicle.

  • The CC ligaments are repaired and/or augmented with a coracoclavicular screw or suture.

  • Repair of deltotrapezial fascia

From Nuber GW and Bowen MK, JAAOS, 5:11, 1997



Techniques for late surgical treatment of acromioclavicular injuries
Techniques for Late Surgical Treatment of Acromioclavicular Injuries

  • Reduction of AC joint and repair of AC and CC ligaments

  • Resection of distal clavicle and reconstruction of CC ligaments (Weaver-Dunn Procedure)


Case example3
Case Example Injuries

AP View

Zanca View


Case example4
Case Example Injuries

After Weaver-Dunn

procedure


Sternoclavicular joint
Sternoclavicular Joint Injuries

From Wirth MA and Rockwood CA, JAAOS, 4:268, 1996


The anatomy of the sternoclavicular joint
The Anatomy of the Sternoclavicular Joint Injuries

  • Diarthrodial Joint

  • “Saddle shaped”

  • Poor congruence

  • Intra-articular disc ligament. Divides SC joint into two separate joint spaces.

  • Costoclavicular ligament- (rhomboid ligament) Short and strong and consist of an anterior and posterior fasciculus


  • Interclavicular ligament- InjuriesConnects the superomedial aspects of each clavicle with the capsular ligaments and the upper sternum

  • Capsular ligament- Covers the anterior and posterior aspects of the joint and represents thickenings of the joint capsule. The anterior portion of the ligament is heavier and stronger than the posterior portion.


Epiphysis of the medial clavicle
Epiphysis of the Medial Clavicle Injuries

  • Medial Physis- Last of the ossification centers to appear in the body and the last epiphysis to close.

  • Does not ossify until 18th to 20th year

  • Does not unite with the clavicle until the 23rd to 25th year


Radiographic techniques for assessing sternoclavicular injuries
Radiographic Techniques for Assessing Sternoclavicular Injuries

  • 40-degree cephalic tilt view

  • CT scan- Best technique for sternoclavicular joint problems

From Wirth MA and Rockwood CA, JAAOS, 4:268, 1996


Injuries associated with sternoclavicular joint dislocations
Injuries Associated with Sternoclavicular Joint Dislocations Injuries

  • Mediastinal Compression

  • Pneumothorax

  • Laceration of the superior vena cava

  • Tracheal erosion

From Wirth MA and Rockwood CA, JAAOS, 4:268, 1996


Treatment of anterior sternoclavicular dislocations
Treatment of Anterior Sternoclavicular Dislocations Injuries

  • Nonoperative treatment

    • Analgesics and immobilization

    • Functional outcome usually good

  • Closed reduction

    • Often not successful

    • Direct pressure over the medial end of the clavicle may reduce the joint


  • Treatment of posterior sternoclavicular dislocations
    Treatment of Posterior Sternoclavicular Dislocations Injuries

    • Careful examination of the patient is extremely important to rule out vascular compromise.

    • Consider CT to rule out mediastinal compression

    • Attempt closed reduction - it is often successful and remains stable.


    Closed reduction techniques
    Closed Reduction Techniques Injuries

    • Abduction traction

    • Adduction traction

    • “Towel Clip” - anterior force applied to clavicle by percutaneously applied towel clip


    Operative techniques
    Operative Techniques Injuries

    • Resection arthroplasty

      • May result in instability of remaining clavicle unless stabilization is done.

      • Suggest minimal resection of bone and fixation of medial clavicle to first rib.

    • Sternoclavicular reconstruction with suture, tendon graft.

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